Pamela R. Wood

Impact of obesity in asthma: evidence from a large prospective disease management study

BACKGROUND asthma and obesity continue to have a significant effect on public health. It is widely accepted that obesity may be an independent risk factor for asthma and affect asthma severity and quality of life (QOL). OBJECTIVE to examine the relationship between body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) and asthma severity, spirometry findings, health care utilization (HCU), and QOL. METHODS this 12-month prospective randomized controlled trial comparing disease management with traditional care enrolled 902 patients (473 pediatric and 429 adults) representing an underserved population. Data collected at baseline and at 6-month intervals included demographics, asthma severity, medication use, spirometry findings, and HCU. The QOL was assessed using the pediatric and adult versions of the Asthma Quality of Life Questionnaire and the 36-Item Short Form Health Survey. All HCU was determined by means of patient interview and extensive medical record review. Data were analyzed using negative binomial regression and analysis of variance. RESULTS in children, 45% were overweight/obese (17% with BMIs >85th percentile; 28% with BMIs ≥ 95th percentile). In adults, 58% were obese (BMIs ≥ 30). There was no relationship in children between BMI and severity of asthma, spirometry findings, QOL, or HCU. In adults, there was no relationship between BMI and asthma severity or HCU. Higher BMI was associated with a significant reduction in QOL (P < .001). The BMI had an inverse relationship with forced vital capacity but with no other spirometric values. CONCLUSIONS obesity was not associated with worse asthma severity, spirometry findings, QOL, or HCU in children. In adults with asthma, obesity was associated with lower forced vital capacity and QOL but not with severity or HCU.

Relationships Between Welfare Status, Health Insurance Status, and Health and Medical Care Among Children With Asthma

OBJECTIVES This study evaluated the relationships between health insurance and welfare status and the health and medical care of children with asthma. METHODS Parents of children with asthma aged 2 to 12 years were interviewed at 6 urban clinical sites and 2 welfare offices. RESULTS Children whose families had applied for but were denied welfare had more asthma symptoms than did children whose families had had no contact with the welfare system. Poorer mental health in parents was associated with more asthma symptoms and higher rates of health care use in their children. Parents of uninsured and transiently insured children identified more barriers to health care than did parents whose children were insured. CONCLUSIONS Children whose families have applied for welfare and children who are uninsured are at high risk medically and may require additional services to improve health outcomes.

Mycoplasma pneumoniae in children with acute and refractory asthma

BACKGROUND The presence of Mycoplasma pneumoniae has been associated with worsening asthma in children. Sensitive assays have been developed to detect M pneumoniae-derived community-acquired respiratory distress syndrome (CARDS) toxin. OBJECTIVES To identify the frequency and persistence of M pneumoniae detection in respiratory secretions of children with and without asthma and to evaluate antibody responses to M pneumoniae and the impact of M pneumoniae on biological markers, asthma control, and quality of life. METHODS We enrolled 143 pediatric patients (53 patients with acute asthma, 26 patients with refractory asthma, and 64 healthy controls; age range, 5-17 years) during a 20-month period with 2 to 5 follow-up visits. We detected M pneumoniae using CARDS toxin antigen capture and polymerase chain reaction and P1 adhesin polymerase chain reaction. Immune responses to M pneumoniae were determined by IgG and IgM levels directed against CARDS toxin and P1 adhesin. pH was measured in exhaled breath condensates, and asthma control and quality of life were assessed using the Asthma Control Test and Pediatric Asthma Quality of Life Questionnaire. RESULTS M pneumoniae was detected in 64% of patients with acute asthma, 65% with refractory asthma, and 56% of healthy controls. Children with asthma had lower antibody levels to M pneumoniae compared with healthy controls. Exhaled breath condensate pHs and asthma control and quality of life scores were lower in M pneumoniae-positive patients with asthma. CONCLUSION The results suggest that M pneumoniae detection is common in children, M pneumoniae detection is associated with worsening asthma, and children with asthma may have poor humoral immune responses to M pneumoniae.

Modifiable Risk Factors for Asthma Morbidity in Bronx Versus Other Inner-City Children

Background: Bronx children have higher asthma prevalence and asthma morbidity than other US children. Objective: To compare risk factors for asthma morbidity present in Bronx children with those of children from other US inner-city areas. Methods: Cross-sectional, multi-state study of 1772 children ages 5–11 yrs. old with persistent asthma. Parental responses to the Child Asthma Risk Assessment Tool for 265 Bronx children are compared with those of 1507 children from 7 other sites (1 Northeast, 2 South, 2 Midwest, 2 West). Results: Bronx children were significantly more likely to be sensitized to reported aeroallergens in their homes than were children from the other sites (86% vs. 58%; p <.001). More Bronx parents reported household cockroaches (65% v 20%; p <.001), mice (42% v 11%; p <.001), and rats (7% v 3%; p <.001); using a gas stove to heat the home (20% v 9%; p <.001); and visible mold (48% v 25%; p <.001). Bronx parents were more likely to report pessimistic beliefs about controlling asthma (63% v 26%; p <.001) and high parental stress (48% v 37%; p <.01). Conclusions: Compared with other inner-city children with asthma, Bronx children are more likely to be exposed to household aeroallergens to which they are sensitized and have poor housing conditions. Their parents are more likely to report low expectations for asthma control and high levels of psychological stress. Interventions that address these identified needs may help to reduce the disproportionate burden of asthma morbidity experienced by Bronx children.

Asthma risk factor assessment: what are the needs of inner-city families?

BACKGROUND A complex array of risk factors contributes to sustained high levels of asthma morbidity in inner-city children. OBJECTIVE To describe risk factors for asthma morbidity in a national sample of inner-city children with persistent asthma. METHODS This study examined baseline questionnaire results from 1,772 children ages 5 to 11 years old with moderate to severe persistent asthma who enrolled in the Centers for Disease Control and Prevention-funded Inner-City Asthma Intervention between April 2001 and March 2004. Risk for asthma morbidity was assessed in 9 domains using the Child Asthma Risk Assessment Tool. The domains included environmental exposures, parental stress, medication adherence, pessimistic asthma beliefs, smoke exposure, aeroallergen exposure, child psychological well-being, responsibility for medication administration, and medical care. RESULTS A total of 51% of families demonstrated high risk of asthma morbidity in 3 or more domains. High risk of asthma morbidity was suggested based on household environmental exposures (47.7%), high parental stress (38.5%), poor medication adherence (38.3%), pessimistic asthma beliefs (31.8%), environmental tobacco smoke (24.4%), sensitization to aeroallergens in the home (24.8%), child behavioral or emotional concerns (22.9%), child assigned responsibility for medication administration (21.2%), and poor medical care (20.7%). Allergy testing was completed for 40% of the participating children. Of these children, 61% were exposed to aeroallergens in their home to which they were sensitized. CONCLUSIONS In this national sample of inner-city children, multiple risk factors for asthma morbidity were identified. Asthma programs that provide multilevel support and intervention are needed to reduce the burden of asthma on inner-city families.

Implementation of an asthma intervention in the inner city

BACKGROUND Despite availability of asthma self-management interventions for children, few have been implemented in community-based settings. OBJECTIVE To describe implementation of the Inner-City Asthma Intervention and factors associated with higher rates of program completion by enrollees. METHODS Descriptive analyses of data from multiple data sources. Two-tailed Pearson correlation coefficients and analyses of variance were used to calculate associations of descriptive variables with the retention rate (percentage of enrolled children who completed the core intervention and had more than 1 follow-up visit) and with the percentage who had allergy testing done. RESULTS A total of 4,174 children were enrolled at 22 sites; 2,153 (52%) completed the core intervention and had more than 1 follow-up visit. A total of 2,014 enrolled children (48%) were tested for allergies. Retention was related to type and location of site, ease of obtaining written plans, language and ethnicity of asthma counselor, and on-site allergy testing. Higher rates of allergy testing were associated with the same factors, as well as flexibility in scheduling and selective enrollment of participants. CONCLUSIONS Inner-city children with asthma can be enrolled in the Inner-City Asthma Intervention outside a controlled research setting. However, completion of all intervention components is difficult to achieve. We identify having an asthma counselor who is representative of the community, access to asthma action plans, and on-site allergy testing as factors that facilitate the implementation of this intervention in community-based settings.

Assessing the value of disease management: impact of 2 disease management strategies in an underserved asthma population

BACKGROUND The goal of disease management (DM) is to improve health outcomes and reduce cost through decreasing health care utilization. Although some studies have shown that DM improves asthma outcomes, these interventions have not been examined in a large randomized controlled trial. OBJECTIVE To compare the effectiveness of 2 previously successful DM programs with that of traditional care. METHODS Nine hundred two individuals with asthma (429 adults; 473 children) were randomly assigned to telephonic DM, augmented DM (ADM; DM plus in-home visits by a respiratory therapist), or traditional care. Data were collected at enrollment and at 6 and 12 months. Primary outcomes were time to first asthma-related event, quality of life (QOL), and rates of asthma-related health care utilization. Secondary outcomes included rate of controller medication initiation, number of oral corticosteroid bursts, asthma symptom scores, and number of school days missed. RESULTS There were no significant differences between groups in time to first asthma-related event or health care utilization. Adult participants in the ADM group had greater improvement in QOL (P = .04) and a decrease in asthma symptoms (P = .001) compared with other groups. Of children not receiving controller medications at enrollment (13%), those in the intervention groups were more likely to have controller medications initiated than the control group (P = .01). Otherwise, there were no differences in outcomes. CONCLUSIONS Overall, participation in asthma DM did not result in significant differences in utilization or clinical outcomes. The only significant impact was a higher rate of controllermedication initiation in children and improvement in asthma symptoms and QOL in adults who received ADM.

Implementation of individualized patient education for Hispanic children with asthma

An educational program known as the Childhood Asthma Project (CAP) was implemented to reduce morbidity among Hispanic children with chronic asthma. Seventy-three children, ages 6-16, participated in 4 program phases: baseline assessment, one-on-one child-centered education, application, and maintenance. During baseline assessment, child and parent asthma beliefs and behaviors were evaluated and used to create educational modules on symptom recognition, peak low meters, medications, and precipitating factors in Spanish and English. Children learned the importance of self-management, practiced using inhalers and peak flow meters and charted peak flow recordings. Videotapes provided peer modeling by showing Hispanic children with asthma performing self-management tasks. During the application phase, patients practiced self-management behaviors at home and reviewed progress with a nurse educator. During maintenance, the success of self-monitoring was reviewed at follow-up appointments. Recommendations for designing health education interventions for Hispanic children are provided.

The Inner-City Asthma Intervention: description of a community-based implementation of an evidence-based approach to asthma management

BACKGROUND In 2000, the Centers for Disease Control and Prevention funded a 4-year project to implement the Inner-City Asthma Intervention (ICAI)-an asthma treatment and management project based on the protocol developed for the National Cooperative Inner-City Asthma Study (NCICAS) funded by the National Institutes of Health, National Institute of Allergy and Infectious Disease. OBJECTIVE To describe the ICAIs major components and implementation issues. METHODS Information contained in this article is based on project activity and management reports, site client tracking and data collection reports, site visit and other program oversight activity, and general subject matter knowledge. The site client tracking data collection process varied among sites during the intervention. Common definitions and processes were developed and implemented as needed. RESULTS Three of the 24 original sites discontinued participation. The remaining sites enrolled 4,174 children into the intervention. Although the project ended earlier than originally scheduled, 1,035 children completed the entire intervention. Of the 3,139 children who did not complete the entire protocol, 1,355 children and their families completed the core activities or the core activities plus one or more follow-up activities. CONCLUSION The ICAI project demonstrated that although there were a number of implementation issues to overcome, it is possible to implement effectively a proven National Institutes of Health protocol in the community setting.

Asthma Epidemiology, Pathophysiology, and Initial Evaluation

The prevalence of asthma and the burden of disease remain high, despite efforts to improve public awareness about and medical management of asthma. Asthma is a disease of airway inflammation that has a variable natural history. Atopy is the most important risk factor for the development of asthma.